MANAGEMENT OF OBESITY IN DIABETES

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MANAGEMENT OF OBESITYIN DIABETES

• 2003 Clinical Practice Guidelines
• for the Prevention and Management
• of Diabetes in Canada

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OBESITY

• An estimated 80 to 90 of persons with type 2
  diabetes are overweight.
• Weight loss improves glycemic control by
  increasing insulin sensitivity and glucose uptake
  and diminishing hepatic glucose output.

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OBESITY

• The initial assessment of people with diabetes
  should include height and weight measurements
  (and calculation of body mass index) and waist
  circumference to assess the degree of abdominal
  fat.
• Waist circumference values ? 102 cm in men and ?
  88 cm in women are associated with substantially
  increased abdominal fat accumulation and health
  risks.

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BODY MASS INDEX
Classification Body Mass Index (kg/m2) Risk of developing health problems
Underweight lt 18.5 Increased
Normal weight 18.5 - 24.9 Least
Overweight 25 - 29.9 Increased
Obese Class I Class II Class III ? 30 30 - 34.9 35 - 39.9 ? 40 High Very high Extremely high
BMI values are age and gender independent, and
may not be correct for all ethnic populations.
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TREATMENT GOALS

• Reduce body fat.
• Attain maintain a healthy body weight for the
  long term.
• Prevent weight gain.

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TREATMENT

• A modest weight loss of 5 to 10 of initial body
  weight can substantially improve insulin
  sensitivity and glycemic control, high blood
  pressure and dyslipidemia.
• Lifestyle interventions that combine dietary
  modification, increased and regular physical
  activity and behaviour therapy are the most
  effective.
• All weight-loss diets must be well balanced and
  nutritionally adequate.

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PHARMACOTHERAPY

• Pharmacotherapy for overweight people with
  diabetes can improve glycemic control and result
  in a reduction in the dosages of
  antihyperglycemic medications.
• Pharmacotherapy is an acceptable adjunct in the
  short and long-term management of obesity when
  lifestyle measures fail after an adequate trial
  of 3 to 6 months.

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ANTI-OBESITY DRUGS
Class Generic Name Trade Name Action
Noradrenergic and serotoninergic reuptake inhibitor sibutramine Meridia Enhances satiety and decreases hunger
Gastrointestinal lipase inhibitor orlistat Xenical Reduces dietary fat absorption nonsystematic
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SURGERY

• Surgery can be considered for carefully selected
  patients after evaluation by an interdisciplinary
  team. Surgery is usually reserved for people with
  class III (or class II, with comorbidities)
  obesity.
• The Roux-en-Y gastric bypass appears to be the
  most successful and preferred procedure.

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OBESITY- RECOMMENDATIONS

• An interdisciplinary program of lifestyle
  modification, including regular physical activity
  or exercise and calorie reduction, should be
  implemented to promote long-term weight loss,
  weight maintenance and prevention of weight gain
  Grade D, Consensus.

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OBESITY- RECOMMENDATIONS

• A weight-loss goal of 5 to 10 of initial body
  weight over a 6-month period should be
  recommended to improve overall metabolic and
  glycemic control in obese people with type 2
  diabetes Grade C, Level 3.
• The recommended energy deficit should be
  approximately 500 kcal/day, which can lead to an
  expected weight loss of 1 to 2 kg/month (2 to 4
  lbs/month) Grade D, Consensus.

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OBESITY- RECOMMENDATIONS

• In obese people with type 2 diabetes, medical
  therapy with the antiobesity agent orlistat
  (gastrointestinal lipase inhibitor) Grade A,
  Level 1A or sibutramine (norepinephrine and
  serotonin reuptake inhibitor) Grade B, Level 2
  may be considered as an adjunct to lifestyle
  modification to expedite achievement of
  weight-loss goals and weight maintenance.

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OBESITY- RECOMMENDATIONS

• For individuals with class III obesity (BMI ?
  40.0 kg/m2) or class II obesity (BMI 35.0 to
  39.9 kg/m2) with comorbidities who are unable to
  achieve weight-loss goals following an adequate
  trial of lifestyle intervention, bariatric
  surgery may be considered to reduce metabolic
  comorbidities Grade C, Level 3.